Family and Children's Medicaid MA-3265 MEDICAID FAMILY PLANNING WAIVER

III. INTAKE PROCEDURES

The application form to be used by outreach organizations, the county departments of social services and for mail-in applications is the DMA-5063, Health Check/NC Health Choice for Children Application. The Adult Medicaid application forms, DMA-5008 and DMA-5000, may be used if an applicant applied for MAABD and it was determined he was ineligible for ABD. The worker then evaluates for FPW. See III.E. below.

Evaluate eligibility for full Medicaid benefits and if ineligible for another Medicaid program, consider coverage under FPW. Give the applicant the DMA-3150, Family Planning Waiver Brochure.

A. An application may be made at the Department of Social Services using the DMA-5063 or an adult application, or

B. An individual may obtain the DMA-5063 application or request an application by telephone, mail, or the DMA internet home page. The DMA-5063 application may then be completed and mailed in, or

REVISED 11/01/11 – CHANGE NO. 15-11

(III.)

C. Individuals may obtain the DMA-5063 application at the Health Department or other outreach locations determined by county DSS.

D. Who May Be Eligible

1. Women who are age 19 through 55, or

2. Men who are age 19 through 60; and

3. Are at or below 185% of the federal poverty level.

E. The Application and Redetermination Form

Any application or redetermination form may be used to apply or be evaluated for FPW.

1. The primary application for FPW is the DMA-5063, Health Check/ NC Health Choice Application. If needed, use the supplements to evaluate for MAF eligibility. A question, 3.c., on the application asks if any individuals are interested in applying for family planning services.

If the applicant answers “yes” to question 3.c., then the DMA-5063A, Medicaid Family Planning Waiver (FPW) Application Addendum, or the Spanish version DMA-5063As must be completed before an evaluation for FPW can be completed. This addendum asks the applicant if he or she meets the age and sterilization requirements.

2. The 5063R, Health Check/NC Health Choice Re-enrollment Form, does not include a question asking if an individual is interested in applying for family planning services. If it appears the recipient is only eligible for FPW, you must ask if he or she is interested in applying for these services. If the response is “yes”, then complete a DMA-5063A/DMA-5063As, Medicaid Family Planning Waiver (FPW) Application Addendum.

3. Any adult application or redetermination document may be used to apply or be evaluated for FPW. A question asking if an individual is interested in applying for family planning services and the question on the DMA-5063A/DMA-5063As, Medicaid Family Planning Waiver (FPW) Application Addendum, are included on the adult applications and all redetermination forms. If one of these applications or forms is used to evaluate for FPW, the DMA-5063A/DMA-5063As, Medicaid Family Planning Waiver (FPW) Application Addendum, is not required.

REISSUED 11/01/11 – CHANGE NO. 15-11

(III.E.)

4. If any application or redetermination form is submitted which does not include the question asking if the applicant/recipient (a/r) would like to apply for FPW, the Income Maintenance Caseworker (IMC) must contact the a/r and ask if he would like to apply for FPW. If he answers “yes” then the DMA-5063A/DMA-5063As, Medicaid Family Planning Waiver (FPW) Application Addendum, must be completed.

5. The DMA-5063A/DMA-5063As, Medicaid Family Planning Waiver (FPW) Application Addendum, may be completed by telephone contact with the applicant/recipient (a/r) or by mail. If the form is mailed to the a/r and it is not returned by the deadline given, send the appropriate notice and terminate or deny Medicaid.

F. Family Planning Waiver Applications and the Eligibility Information System (EIS)

Register applications for FPW in EIS as MAF. Eligibility for FPW Medicaid is reflected by a different Medicaid classification code of “D”. If eligible for FPW Medicaid, use the Medicaid class code of “D”.

1. Family Planning Indicator

The Family Planning Indicator on the DSS-8124 Application Screen in EIS must be marked Y for Yes, they want FPW or N for No, they do not want FPW. The indicator may be changed at any time prior to the disposition of the application.

2. Source Field Indicator

Enter the appropriate code to indicate the source from which the application was received: “D” for County DSS; “H” for Public Health department; “M” by mail.

3. Automated Notices

The notice codes and text are contained in EIS 4000, Appendix B.

4. Medicaid Handbooks

A Consumer’s Guide to North Carolina Medicaid Health Insurance Programs for Families and Children Handbook will be mailed at the disposition of the application if the application was received by mail or from the Health Department and is coded as such on the DSS-8124 Application Screen in EIS. The worker must give the handbook to the applicant during a face-to-face interview.

REVISED 11/01/11 – CHANGE NO. 15-11

(III.)

G. Applications Taken at the DSS

Intake procedures are not changed for in-house applications. Process all applications as if the applicant is applying for full Medicaid.

If the applicant specifies that he or she only wants to apply for coverage through Family Planning Waiver, explain that the applicant must be evaluated for regular Medicaid first.

If the application used requires the completion of a DMA-5063A/DMA-5063As, Medicaid Family Planning Waiver (FPW) Application Addendum, this must be completed by either telephone contact or by mail before completing an application or review. (See III.E.)

1. Log Procedures

Follow procedures in MA-3200, Initial Contact, to log requests for assistance.

2. Inquiries

Complete the DMA-5095/5095S, Notice of Inquiry, only if no application is taken for any program.

3. Complete a DMA-5063 following procedures in MA-3205, Conducting a Face to Face Intake Interview. If the applicant answers “yes” to question 3.c., complete a DMA-5063A/DMA-5063As, Medicaid Family Planning Waiver (FPW) Application Addendum.

If the applicant answers “yes” to the question on the DMA-5063A, continue with the application process. If the applicant answers “no” to the question, deny the application.

4. Medicaid Family Planning Waiver Services

Explain services available to the Medicaid recipient. Give the applicant the DMA-3150, Family Planning Waiver Brochure. Use the DMA-5074, Medicaid Family Planning Waiver Fact Sheet, as a guide to give an overview of the program. Do not give the DMA-5074, to the client. Advise the applicant that if approved for FPW, the Division of Public Health or health care providers will provide more detailed information about covered services and how to obtain them at the initial family planning office visit. Information also may be obtained from the Division of Medical Assistance. Services include (Not all inclusive.):

REISSUED 11/01/06 – CHANGE NO. 17-06

(III. G. 4)

a. Annual family planning exam that includes pap smear and breast exam for women and a testicular exam for men,

b. Counseling and contraceptive supply visits to support the effort to continue a pregnancy spacing plan,

c. Most methods of birth control,

d. Screening for STI (Sexually Transmitted Infections),

e. Screening for HIV (Human Immunodeficiency Virus),

f. Sterilizations for men and women over age 21.

5 . Processing the Application

Register the application in EIS as MAF.

a. Use the DMA-5097/5097S, Request for Information, to request information necessary to determine eligibility.

b. Follow existing procedures in MA-3302, Verification Requirements, and MA-3303, Application Processing, for requests for information, pending periods, etc.

c. If it is established that the application is for FPW, complete the application no later than the 45th day.

H. Mail-In Applications

For processing purposes, a "mail-in" application is defined as any application in which there is no face to face interview completed by the IMC. This includes applications which are mailed in or completed in another agency (e.g. health department) and routed to the dss. See MA-3207, Receiving Mail in Applications.

If the applicant answers “yes” to question 3.c. on the DMA-5063, contact the applicant via mail or telephone to complete a DMA-5063A/DMA-5063As, Medicaid Family Planning Waiver (FPW) Application Addendum for each applicant requesting FPW. If the mailed DMA-5063A/DMA-5063As is not returned, deny the FPW application.

If the applicant answers “yes” to the question on the DMA-5063A/DMA-5063As, continue with the eligibility review. If the applicant answers “no” to the question, deny the application.

REVISED 11/01/06 – CHANGE NO. 17-06